Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, February 27, 2008

Feeding Tubes

Few phone calls are more annoying for a general surgeon than the inevitably late night ER page about a patient from a nursing home who is "having problems" with a feeding tube that you may or may not have placed. It's clogged. It's leaking. It fell out. It hurts. And most medical personnel are terrified of them. No one knows exactly what to do and so it gets dumped on us.

Feeding tubes are an alternative to stuffing food down your mouth. Instead of filet mignon or smoked salmon, you get to infuse delicious Boost through a thin silastic or rubber tube directly into the stomach or small bowel, bypassing your taste buds and any enjoyment usually associated with eating. This isn't something you want. Unfortunately, certain conditions make them necessary such as strokes, swallowing difficulties, chronic aspiration, esophageal tumors, and other states of inanition. You also find feeding tubes placed in certain post-operative patients (Whipple, Gastric and esophageal tumors) as a way to provide enteral nutrition while more proximal anastomoses are healing.

Feeding tubes come in 2 varieties:1. Gastrostomy tubes. These tubes are inserted into the stomach. More commonly nowadays, these tubes are placed percutaneously (Percutaneous Endoscopic Gastrostomy...PEG). Open or laparoscopic G-tubes are also an option if the percutaneous route is not available. G-tubes provide a little more flexibility in terms of feeding schedules because the stomach is such a large reservoir. Bolus feeds and continuous feeds are options. It's also easier to give medicines via a G-tubes because generally the tubes themselves are of largr caliber.

2. Jejunostomy tubes. These tubes are best used for feeding purposes when the stomach is not suitable or available. Now the jejunum is of a much narrower caliber than the stomach. Bolus feeds usually don't work and I worry about giving medicines, even crushed, via J-tubes because of clogging issues.

Biggest problems:

1. Clogged tubes. This is almost universally a result of poor nursing management. Enteral tube feed formulas are like wet cement; as long as the flow is steady and constant there's no worries. But if the feeds are turned off and the wet cement is allowed to stagnate in the tubing, it quickly solidifies and completely obstructs the lumen. The key is prevention and this means q4 hour flushings with saline or water. And any time the feeds are stopped (patient being transported somewhere) you HAVE TO FLUSH THE TUBE! It's an entirely avoidable complication as long as the tube is appropriately flushed on a regular basis. Most of the time I can clear it by power flushing the tube, but sometimes you have no choice but to replace the entire tube. Just thinking about this complication makes my heart rate accelerate because it's due to laziness.

2. Leaking tubes. Over time the exit site on the skin can sometimes enlarge and you can get minor enteric leakge on the abdominal wall. Lots of bile leakage should alert you to the possibility of distal bowel obstruction, or even a defect in the tubing itself.

3. Tubes that fall out. Happens all the time. Usually it's an elderly lady at the nursing home, demented and confused who yanks it out unknowingly. Most of time, especially with G-tubes, I can simply put another tube in through the established tract. Expediency is the key. The more time that elapses with the tube out, the harder it is to place a new one because scar tissue starts to form. J-tubes are a little dicier because I worry about perforating the bowel wall with blind insertion into the narrow jejunum; I like doing these with fluoroscopic guidance to confirm that the tip is actually within the lumen of bowel.

20 comments:

I had a little granddaughter who was born with almost no brain. She was unable to suckle or swallow, so finally at eight months the pedi surgeon put in a G-tube. He started out with a Foley, but it kept getting into her Pylorus. Next, they put in a Pezar. My daughter and I were both nurses and I was capable of popping the old one out and she was able to stick the new one in with a stylet. We both had our shortcomings, but managed between the two of us. This little girl was given two years to live and managed to live nine and a half years with nothing to eat, but Vital. Life is tough.

anon- I've had those guys perforate the jejunum before. I also recently saw a patient who had a j-tube that had fallen out with a PEG apparatus; the balloon was 20 cc of saline and it just obstructed everything distally. I'd rather do it myself.

kacey- well spoken. Hopefully those 9 years of life provided moments of fulfillment for you and your daughter.

Feeding tubes are as vexing as they are lifesaving. I had a patient who needed one for the last eight years of life. It kept him alive but gave him no peace - pain, dysfunction, intermittent obstruction, and wildly fluctuating bowel habit changes.

By the way, on behalf of all referring docs, I apologize for the problem feeding tube consults. It is amazing that the cracked port, leaking tube, excoriated site, mysterious pain, "doesn't look right" tubes show up on Fridays. Fortunately, my surgery colleagues are wonderfully responsive. Maybe that’s why they get the calls.

Bruce-No need to apologize. Someone has to take care of them. Most of the time, the phone calls I get are directly from nursing homes, after hours, from non-physicians who have a hard time describing what the heck is going on...

I am 28 years old and had a j-tube placed 3 years ago for severe gastroparesis. It was changed to a low profile j-tube 1 year ago. My GI doc finally allowed me to remove the j-tube a couple of weeks ago. My question is though the site where my j-tube was is still leaking bile at times. It is a pinhole and looks like it should be closed up. But, it is still leaking bile every day. I'm 2 weeks post having the j-tube pulled. Is this normal?? When can I expect the hole to close?? Thank you.

Most of these will close in 1-6 weeks. After 6 weeks, you ought to be concerned. Also: quantity of drainage is helpful in predicting how quickly it closes. Is there just a little drainage or do you have to change the dressings every hour or so.... see a surgeon if it's the latter.

Hi Everyone this site is wonderful and really right on. I'm in the middle of what appears to be a very bad dream. To make a long story short my father recently hsad a j tube put in due to a stroke and a very large hernia where him stomache sits above the diapham. His J tube is a cope week old, he what hospitalized at Mercy Hospital in Pittsburgh PA everything was run very smoothly in the hospital for a 2 week period. He was discharge to a nursing home on a Wed. by Sat the nursing had the j tube clogged and started cut parts off to fix there problem. They sent him to a nother hospital who had not done the surgery and shipped him back to the nursing home without repair. My father started off at 240 lbs. now 150lbs and going down hill quickly. The following day he was taken to Mercy where they had to try to fix the mess the nursing home made to his feeding tube. Thanks doctors for getting him up and running again. The family did not return him to the same nursing home. He was moved to a new nursing home on Monday....well here it is Thursdday right before a holiday weekend and guess what a call from the nursing home they feeding tube is clogged again. The nursing is going to wait til Monday....The family doctor demanded to get him to the hospital....hopefully getting a hold a the surgeon who performed the surgery...not to wait to Monday for feeding, fluids and medications.....Anybody out there with any help??????to this reoccurring problem. Also we just learned he wasn't taken by a new nursing home because of the J-tube. Anyone can help our family is overwhelmed from repeated trips to the hospital and nursing home staff who are not trained to handle j-tube or who is over worked. Also how soon after a new J-tube could in be replace. The first nusing home told us the stomache acid was eatting the tube and destorying it. Would love to hear from anyone out there? Sorry doctor's I know itas the famous weekend, evening, holiday problem. Deb

Please advise how safe it is for a nurse to replace a j tube in the patients nursing home room. This patient has recently had MRSA and ecoli! Please advise as the patients family always had the tube replaced at the gastro doctor and was never notified the last two times the tube fell out until after the fact. The nursing home knows the families desires as he was taken from there many times for the procedure.The last couple of times the family was never notified until after the fact. Thank you! Concerned loved one.

anons-Feeding J tubes are a tough issue because problems invariably develop and when they do, it usually happens on weekends/holidays at nursing homes where the personell is less equipped to deal with the problems. All I can say is: always try to have the surgeon who placed the tube be made aware of any problems early in the game. I don't like having a nurse exchange J-tubes at the bedside because there's a small risk of perforation/etc. G tubes can be exchanged as needed by anyone.

I have a pt with severe Gastric varices who had a stroke and developed dysphagia. He had a g tube put in and was sent to my nursing home. he pulled the tube out with the one working limb that he has, and now its a weekend..... my local surgeon does not do J tubes and the soonest i can get him in is Monday. How safe is an NG tube to use temporarily in a case of severe gastric varices that are not actively bleeding? Incidentally, this patient has 4 BP meds and 2 seizure meds. Or should we just leave him on D5NS IV Fluids till Monday, which is about 3 days away?

I am sitting in the ICU waiting room. My father has PSP and has problems swallowing and aspirates, currently has doulble phnemonia. The DR said a Peg cannot be placed in stomach (or anywhere else) b/c of the scar tissue from a surgury he had in 1979 when a portion of his stomach was removed due to ulcers. Do you have any other suggestions for long term nutrition?Thanks tabatha_durick@beaerospace.com

A little off topic, Guys... I have a question. Two days ago I discovered this site:[url=http://www.rivalspot.com]Rivalspot.com - Ps3 Live Tournaments[/url] They say you can play online NHL game tournaments on any console for cash... had anyone tried that before? Looks like a cool idea... Are there any other sites where you can play sports games for real moneys? I Googled and found only Bringit.com and Worldgaming.com but it looks these guys don't specialize in sport gamez. Any suggestions?

My mother-n-law came home to for me to care for her Oct 8, 2010. She had a brain absess,and followed by meningitis...She is total care, I am sure she had a stroke on top of this but I'm still waiting on her medical records. When she came to me she had a trach,foley,g-tube. Last night at 830pm I went to chang her diaper and there was a tube coming from her anus! I'm a nurse but was in total shock and didn't know what to do, I was afraid to pull it. I checked placement on her g-tube, all sounded great, bowel sounds present, gently tugged on the foley and seemed to be in place plus its draining urine! After calling several persons I pulled it out--it was 18 inches long!!!! I am still in shock. It had to be her dobhoff or a J tube from May--its now November! Thank God it passed but what the heck! Has anyone experienced or seen this? She appears to be in no distress, actually better today and vital signs are stable.

Why Dont someone come up with a J tube that will stay in and will not clog? I think its because each time it is replaced Doctors and the hospital collect a good amount of money for replacing it !!!! you should figure out how to design one that will stay in and work instead you wont the money from the Insuerance company !!!!! Why make people suffer with this problem? FIX IT!!!Rodney Farrell

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